Treating erectile dysfunction after surgery for pelvic cancers

Objectives of treating erectile dysfunction post surgery

The goal of an erectile function management strategy is the return of assisted and non-assisted erectile function, and prevention of changes to penile length and girth

Treating erectile dysfunction (ED) includes:

minimising extent and duration of ED

improving blood flow and delivery of oxygen to the penis

protecting penile tissue

preventing or minimising any changes to the size and girth of the penis

Erectile function rehabilitation programmes, especially if initiated early on after surgery, are effective in improving or restoring sexual function

Predictive factors for recovery

The recovery of erectile function depends on the following factors:

age of man and partner—younger patients are likely to have better results

phosphodiesterase type 5 inhibitor (PDE5-I) induced erectile function—men with normal erectile capacity, who take PDE5-I tablets before surgery and continue to take them, have the potential to have better erectile function after surgery than those who don't

presence of other health problems—comorbidities increase the risk of ED after surgery (e.g. diabetes, hypertension, and cardiovascular disease)

PDE5-I=phosphodiesterase type 5 inhibitor; VED=vacuum erection device; ICI=intra-cavernosal injection.*Pathway is a collation of survey responses of individual clinical practice.†Tablets can be started before surgery if pre-existing sexual problems are identified during initial assessment or they can be started immediately after catheter removal.‡The most effective combination depends on patient and partner needs, but the commonest favoured combination is VED + PDE5-I. Daily and on demand PDE5-I used simultaneously is an off-label recommendation.§Psychosexual therapy and counselling provided as an adjunct to ED treatment.

Responsibility for prescribing specific treatments is determined at local service level

Duration of treatment The decision to stop treatment depends on each patient, as the recovery time differs from man to man. Ideally, a treatment should be given until it's no longer needed

Treatment initiation

Initiate treatment preferably as soon as catheter is removed, and definitely within the first three months of surgery

In some cases, PDE5-Is can be initiated before surgery—if pre-existing problems are identified at presurgical assessment—or at catheter removal to improve outcomes

Psychosexual therapy and psychological counselling

Enable access to psychosexual therapy or psychological counselling for the patient and his partner pre and postoperatively, particularly where biomedical strategies are ineffective and/or there is patient or couple distress

Encourage partner support for the rehabilitation programme through ongoing psychosexual therapy and couples counselling

Include partners in all decision-making processes if possible

Re-assessment

Once ED management is initiated, re-assess at regular intervals for example at eight weeks, three months and six months—the re-assessment schedule can coincide with the cancer review schedule

Treatment duration

Try each strategy on at least eight occasions before switching to another strategy, unless the patient experiences adverse events warranting an early switch

Individualise duration of treatment for each man, as strict limits are inappropriate in clinical practice

The duration of any treatment can range from three months until the man no longer needs treatment

Assessment of erectile function

Recommendations for assessing erectile function before and after surgery include:

Useful sources of information

Professional support

Free educational resources are available in Macmillan's Learnzone, including 'Sexual Relationships and Cancer', an online module on how to talk to patients about the issues surrounding sexuality and cancer—visit learnzone.org.uk for further information